Medico by completesolutionsinc

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                   AGENT CONTRACTING CHECKLIST 
    1. Complete all portions of Agent Contract and Agent Agreement 
       that apply (if any questions are answered ‘yes’, please provide a 
       written explanation to help speed up your contract through the 
       process) 
       


    2. Direct Deposit Information must be completed and a VOIDED 
       CHECK must be attached 
       


    3. Include current State License(s) 
       


    4. Include a current E&O certificate  
       




If faxing or emailing your contract, please return the pages that you 
actually filled in and signed plus the commission schedule(s). 
                                      

               Return completed contracts to: 
                       Complete Solutions, Inc. 
                            75 N. Dixie Drive 
                         Vandalia, Ohio 45377 
                                   OR 
                          Fax to 937.898.3048 
                                   OR 
                   Email Barb at barbw@csi‐411.com 
 
If you have any questions, please call us at 1.866.866.7951 
                                                          AgtChklst‐E&O 090810 

 
                                                                       Medico™ Insurance Company
                                                   1515 South 75th Street y Omaha, Nebraska 68124
Contracting Checklist



                            MEDICO CONTRACTING CHECKLIST



   Name:

   Agency:



   K Signed Agreement & Personal History

   K Signed HIPAA Business Associate Agreement

   K Signed Acknowledgement of Receipt

   K Producer Life Replacement Policies & Procedures

   K Direct Deposit Authorization

   K Copy of Errors and Omissions Insurance

   K Copy of Producer License for each state in which to be appointed

   K Copy of agency licenses, if applicable




   MI9F-4321                                                                          02122008
                                                                                                   Medico™ Insurance Company
                                                                                1515 South 75th Street y Omaha, Nebraska 68124

                                    CONFIDENTIAL PERSONAL HISTORY
PERSONAL INFORMATION:
Name                                                                                 Social Security No.            -       -
           First                M.I.                Last                    Suffix

Date of Birth                 Sex            Maiden or Other Name Used                              Spouse’s Name
Home Address
                   Street                                    Apt. No.                   City                State         Zip Code

Mailing Address
                    Street                                   Apt. No.                   City                State         Zip Code

UPS Address
                   Street                                    Apt. No.                   City                State         Zip Code

Business Phone No. (            )        -                               Home Phone No. (          )        -
E-Mail Address:                                      Fax No.: (     )      -
IMPORTANT!! E-MAIL ADDRESS IS REQUIRED FOR WEBSITE SIGN ON AND FOR COMMUNICATION FROM HOME OFFICE


TYPE OF CONTRACT:
If you are seeking an appointment on behalf of an agency, is that agency a:
… Sole Proprietorship          … Partnership           … Corporation
FEDERAL I.D. NO.
Is the agency now licensed?            … YES      … NO
Please list all partners or corporate officers:
                       NAME                                             TITLE                          SOCIAL SECURITY NO.




LICENSE INFORMATION:
Are you now licensed?         … YES      … NO
If yes, please indicate below any license(s) you currently hold:
              RESIDENT STATE                    LICENSE OR QUALIFICATION NO.                      TYPE OF LICENSE/LINES

       NONRESIDENT STATE(S)                     LICENSE OR QUALIFICATION NO.                      TYPE OF LICENSE/LINES




WORK HISTORY:
(Please begin with most current employer.)
EMPLOYER/ADDRESS SUPERVISOR NAME                           POSITION HELD                       DATES                PHONE NUMBER
                                                                                     FROM         TO
                                                                                                                (___) ____- ______
                                                                                                                Ok to contact? ______
                                                                                     FROM         TO
                                                                                                                (___) ____- ______
                                                                                                                Ok to contact? ______
                                                                                     FROM         TO            (___) ____- ______
                                                                                                                Ok to contact? ______

MI9F-095                                                        Page 1                                                          02052008
Please answer the following questions:
Has any state ever taken administrative action against your license?                 If so, name state and
provide details:
Have you ever been convicted of a felony?              Details:


Have you ever been short in accounts with any employer or do you currently have a debit balance with
any insurance company?          If so, please explain:


Have you ever been refused bond?               If so, please explain:


Have you ever filed for bankruptcy?            If so, please explain:


Do you have any judgments or garnishments against you?                  Please explain:


Have you been or are you involved in any litigation?              Please explain:




I certify that my answers to the above questions are true and authorize the State Insurance Department to
release to Medico™ Insurance Company information within their records concerning me. If accepted, I will
comply with all regulations of this State and Medico™ Insurance Company and will not solicit insurance until I
have received my license from the State Insurance Department.

I hereby authorize an investigative and credit report whereby information is obtained through personal
interviews; the inquiry usually concerns information on your character, general reputation and mode of living. I
understand that any information obtained by the Company will be available to me upon my written request.


Applicant Signature                                                                 Date



This applicant is recommended for appointment as a Distributor assigned to my jurisdiction, subject to the
terms of my contract with the Company. I certify to the best of my knowledge the applicant is of good personal
and business reputation, trustworthy, and competent to act in the capacity of an insurance agent.


Recruiting Distributor Signature                                                    Date


Request Background Investigation?         … YES     … NO




                     ASSIGN TO COMPLETE SOLUTIONS, INC 75575‐RY15 




MI9F-095                                             Page 2                                             02052008
                          DISTRIBUTOR AGREEMENT

This Agreement entered into between Medico™ Insurance Company, on the one part, and the
undersigned Distributor, on the other part.

DEFINITIONS: As used in this Agreement,

     A. “We,” “Us,” “Our,” “Company,” and “Medico™” mean Medico™ Insurance Company.
     B. “You,” “Your,” and “Yours” mean the Distributor, even though Distributor may be a
        partnership or corporation.
     C. “Solicitor” means an insurance producer who is appointed by Us, but not contracted
        with Us.

1. APPOINTMENT: We appoint You as Our Distributor to procure applications for health
and life insurance of Medico™ if You are licensed to sell these lines of insurance. This
appointment is on a non-exclusive basis and We may appoint other distributors in Your state.

                                      AS DIRECTED BY US

2. YOUR DUTIES: You agree to accept the following duties and responsibilities:

       A. You and Your Solicitors will procure applications for Our insurance. In doing this,
You and Your Solicitors will act according to Our rules and instructions.

         B. Unless there is something that would disqualify them, We will appoint Your
Solicitors. We reserve the right to terminate Your Solicitors. We shall have no liability to any
of Your Solicitors for their compensation or otherwise. You agree that Your contracts with
each of Your Solicitors for Our insurance will not entitle the Solicitor to a greater dollar
amount of compensation, nor for a longer period of time, than You are entitled to from Us on
such business. If You violate this agreement, You will, at Our option, lose all commissions
which are due You thereafter.

        C. You will not permit any of Your Solicitors to solicit for Us until they have been
licensed by the state in which they will solicit and evidence of that license is given to Us.

       D. You will collect in full the first premium with the application on each policy You or
Your Solicitors sell. You will treat these premiums as trust funds for Us. You will remit these
funds and applications to Medico™ in accordance with Our instructions.

          E. You will comply with all state and federal laws, orders, rules and regulations.

       F. You will be responsible for obtaining and maintaining the necessary licenses and
appointments to sell Our products in the states in which You operate, whether resident or
nonresident. You will be responsible for all state and city license fees or taxes, applicable
appointment and termination fees, and occupation fees or taxes. We will pay state taxes on
premiums.

       G. You will reimburse Us any commissions You receive on premiums which are
returned by Us on declined applications or policies canceled or not accepted by the applicant.

        H. You will see that You and each Distributor and/or Solicitor has and maintains or is
covered by errors and omissions liability insurance coverage of at least $1 million per
occurrence or such other level (higher or lower) as may be acceptable to Us throughout the
term of this Agreement and provide evidence of such insurance to Us upon request.




MI-DIST                                          1                                        02132008
3. LIABILITY, INDEBTEDNESS & INDEMNITY: You shall be jointly and severally
liable, with each Distributor and/or Solicitor, to Company for the payment of all (i) monies due
from You or Your Distributors and/or Solicitors, (ii) debit balances on the account of You or
Your Distributors and/or Solicitors, (iii) debit balances resulting from loans to You or Your
Distributors and/or Solicitors, and (iv) all obligations evidenced by documents related hereto.
Company’s books shall be prima facie evidence of such debit balances or loans due.

Any indebtedness incurred by You or Your Distributors and/or Solicitors to Company shall be
payable immediately upon receipt of a written notice from Company. Company may, at any
time in its sole discretion, offset against any remuneration due or to become due You, any past,
present or future debt or debts due from You or Your Distributors and/or Solicitors. Such
indebtedness of You or Your Distributors and/or Solicitors shall be secured by a first lien in
favor of Company on any and all compensation due You and shall be binding upon You and
Your assigns and successors. Upon the termination of this Agreement, any and all money
belonging to Company in the possession of You or Your Distributors and/or Solicitors shall
immediately become due and payable and shall be paid over to Company; but Company may,
in its sole discretion and without waiving its rights, deduct such indebtedness from any
payment provided herein until repaid.

You agree to indemnify Company and its affiliates, shareholders, directors, officers and
employees and to hold Company, its affiliates, shareholders, directors, officers and employees
harmless from any and all expenses, liabilities, costs, cause or causes of action and damages,
including attorneys’ fees and costs of litigation, resulting from or growing out of any breach of
this Agreement or any related documents or any unauthorized, fraudulent, negligent or
wrongful act, omission, statement or representation by You or Your employees or independent
contractors (excluding Distributors who are directly contracted with the Company). Company
agrees to indemnify You and to hold You harmless from any and all expenses, liabilities, costs,
cause or causes of action and damages, including attorneys’ fees and costs of litigation,
resulting from or growing out of any negligent or wrongful act, omission, statement or
representation by Company or Company’s employees. This Section 3 shall survive the
termination of this Agreement for any reason.

4. COMPENSATION: You will be paid the commissions stated in the Commission Schedule,
which is attached hereto, as complete compensation for all that You and Your Solicitors do for
Us. The attached Commission Schedule may be revised from time to time to reflect policies
presently being marketed by Medico™. Where a policy is delivered or issued for delivery in any
state listed under the heading “State Variation,” the commission for that particular state will
apply.

5. COMMISSIONS ON SUBSTITUTED OR REINSTATED POLICIES: When You
substitute one policy for another, Your commission will be governed by Our rules and
regulations regardless of what this Agreement says. When We reinstate or reissue a lapsed
policy without Your efforts and this occurs during the first six months after the policy lapses,
We will pay You commissions on the premiums received for this policy after reinstatement or
reissue at the renewal commission rate for that policy. When You reinstate or rewrite a policy
during the first six months after the policy lapses, We will pay You a commission on the
premium You collect at time of reinstatement or rewrite equal to one-half the regular first-
year commission rate for that policy. We will pay You commissions on subsequent premiums
for the reinstated or rewritten policy at the renewal rate in effect at that time for the policy.
During the 60-day period following the due date of a policy, it must be reinstated and You
cannot rewrite it. During the period which starts 60 days after a policy’s last premium due
date and ends four months later, You may either rewrite the policy or reinstate. After a policy
has been lapsed for a period of six months, You must rewrite the policy. It cannot be
reinstated.




MI-DIST                                         2                                        02132008
6. YOUR STATEMENT: We will send You a statement or transmit an electronic statement
to You showing Your account with Us. However, no statement will be sent when Your account
with Us is zero. If You die, We will send this information to Your spouse or Your estate. You
agree that each statement will be binding on You, Your spouse and Your estate unless You,
Your spouse or Your estate tells Us, within 45 days after the statement is transmitted, that the
statement is wrong.

7. ASSIGNMENT: You cannot assign this Agreement or any amount We owe You without
getting Our written consent first. If You do, the assignment shall not be valid. If We consent to
an assignment by You of the commissions due under this Agreement, the assignment shall be
subject to any amount You owe Us at the time of the assignment. The assignment shall also be
subject to any amount You may owe Us in the future. If We consent to an assignment by You
of this Agreement, You shall remain liable for the performance of the terms of this Agreement
by the person or business entity who receives the commission assignment from You.

8. LIMITED AUTHORITY: You will not accept any risks, change any policies, make any
contracts for Us or obligate Us in any way unless You secure Our written consent first. You
will not change any premium rates or extend the time for paying premiums. You will not
accept applications for any policies without collecting the entire premium due at the time of
sale.

9. LICENSES: This Agreement will end for Medico™ if it does not continue to be licensed in
the state covered by this Agreement. If You give up or lose Your license, this Agreement will
end. If You are not licensed to sell both health and life insurance, this Agreement will apply
only to that line of insurance for which You are licensed. If You later become licensed to sell
either health or life insurance, this Agreement shall also apply to such additional line of
insurance.

10. ADVERTISING: You will not use any advertising or any material not furnished by Us
without getting Our written consent first. All representations or references to Medico™
Insurance Company, its products or producers, in any advertisement or marketing material
shall be submitted to Us prior to its use or distribution and shall not be utilized until You
receive written approval from Us. Advertising includes any material which is designed to
create public interest in Medico™ Insurance Company, its products or producers. This
includes, but is not limited to, consumer material designed to induce the public to purchase,
increase, modify, retain, renew or reinstate a policy or certificate as well as producer recruiting
and training materials. Examples of advertising include, but are not limited to, printed and
published material, business cards, audiovisual material, direct mail material, Internet sites,
newspaper and magazine ads, radio and television scripts, billboards and similar displays,
flyers and ad slicks, leaflets and booklets, brochures, newsletters, form letters, prospect letters,
telephone scripts, lead-generating devices of all kinds, depictions and illustrations, prepared
sales talks, presentations and producer training materials.

11. COMMUNICATION AND TRANSPORTATION EXPENSES: If We phone You or
send anything to You, We pay the cost. If You phone Us or send anything to Us, You pay the
cost.

12. DECLINATIONS: We shall have the right to decline an application without giving any
reasons for doing so.

13. FEDERAL, STATE AND LOCAL LAWS: You agree to obey all federal, state and local
laws and regulations.

14. PROHIBITED ACTIONS: You agree that You will not rebate in any form. You agree
that You will not make any representations to any of Our policyholders to get them to
terminate their insurance.


MI-DIST                                          3                                         02132008
15. RESERVATION OF RIGHTS: We shall not be liable to You for exercising any of the
rights given to Us in Our policies. Examples of these rights are the right to cancel or nonrenew
the policy or to change the premium rates. We shall not be liable to You for withdrawing or
substituting policy forms, nor for Our withdrawing entirely from any state. Further, We
specifically reserve the right without limitation and without liability to You to change or
discontinue any marketing concept or underwriting program in any state, change any policy
premium rate, change the conditions or terms under which a policy may be offered, or reject
any application or return any premium.

16. VESTMENT: Commissions provided for in this Agreement shall be paid for as long as the
policy remains in force, subject to provisions of this Agreement providing otherwise in
Paragraphs 17 and 18, herein. This provision shall survive the termination of this Agreement.

17. TERMINATION: You or We may terminate, without cause, this Agreement by giving at
least 30 days notice to the other parties. You or either of Us may terminate this Agreement
immediately for good cause by giving notice to the other party. Notice shall be given pursuant
to the Notice provision of Paragraph 24, herein. Good cause shall mean:

   A.     Fraud or any breach of the terms of this Agreement.
   B.     Failure to pay any money required by this Agreement to be paid.
   C.     Violation of any federal, state or local laws or regulations.
   D.     Any act or omission by You which could affect the right of Medico™ to do business in
          the state covered by this Agreement.
   E.     Inducing or attempting to induce policyholders to relinquish or replace Our policies
          with such frequency as to indicate a pattern of inappropriate activity.
   F.     Repeatedly failing to comply with material terms of this Agreement and/or Our stated
          rules and regulations concerning recruiting and production requirements for You or
          those under Your hierarchy.
   G.     Cause or attempt to cause employees or agents of Ours to discontinue their association
          with Us.
   H.     Misappropriation or commingling of Our funds.
   I.     Misrepresentation or omission of any material information on an application for a
          policy.
   J.     Misrepresentation of any of Our policies or services.

This provision shall survive the termination of this Agreement.

18. FORFEITURE AND REMEDY: You agree that after this Agreement ends, You will have
no interest in any business written for Us, except as specifically provided in this Agreement.
You agree that if You attempt to influence any of Our policyholders with whom You or Your
Solicitors or Distributors have done business, or Our Solicitors, Distributors or employees, to
terminate their contract or employment with Medico™, or this Agreement is terminated for
good cause as defined in Paragraph 17, herein, You will lose all future commissions from Us.
You also agree that We may secure a court order stopping You from using such influence since
We do not have an adequate legal remedy. This provision shall survive the termination of this
Agreement.

19. MINIMUM AMOUNT OF COMMISSIONS: After this Agreement terminates We will
not pay commissions after any calendar year in which the total commission owed or paid to
You is less than $500.00. If compensation due to You falls below the minimum required, such
amount shall roll up to and be payable to the next level above You in the Distributor
hierarchy.

20. WAIVER: The fact that We may not enforce the terms of this Agreement does not mean
that We waive them or that We will not enforce them at a future time.



MI-DIST                                         4                                       02132008
21. RELATIONSHIP: Nothing in this Agreement shall create a relationship of employee and
employer, or a partnership, between You and Us. You are free to exercise Your own judgment
as to the persons You solicit and where and when You solicit them. However, We may give
instructions, which do not interfere with this freedom, regarding the conduct of Your business
for Us and You will obey these rules.

22. DISTRIBUTOR OR SOLICITOR TRANSFER: The Company will permit a transfer of
a Distributor or Solicitor to another organization pursuant to Our established policies and
procedures.

23. PRIVACY ACT NOTICE: You herein acknowledge You have received a copy of the
Privacy Notice of the Company. You acknowledge and agree You are acting as a third party
services provider to the Company as contemplated in Section 503 of the Gramm-Leach-Bliley
Privacy Act and are therefore bound by the stated policy of the Company regarding the release
of nonpublic information derived by or for the Company in the normal course and conduct of
business.

24. NOTICES: Any notice required by, or provided for, in this Agreement shall be considered
given when it is mailed, postage prepaid, by certified or electronically confirmed mail, return
receipt or electronic confirmation requested, and addressed to the party or parties at their last
known address.

25. This Agreement shall be governed by and construed in accordance with the laws of the
State of Nebraska. Any legal action necessary under this Agreement shall be brought in the
District Court of Douglas County, Nebraska.

26. It is understood and agreed that no policy will be solicited or written until Distributor
receives written notice that the plan is approved in the state in which solicitation is to be
made.

27. This Agreement supersedes and replaces any previous agreements between You and Us.

28. This Agreement is effective                  , 20         .

Accepted, agreed to and signed by the parties:

1. Distributor’s Name
                            (Please Print)


      Taxpayer I.D. or Social Security Number

2. Distributor is:    Individual (Sole Proprietor)      ( )
                      Partnership                       ( )
                      Corporation                       ( )




MI-DIST                                          5                                       02132008
              IF DISTRIBUTOR IS INDIVIDUAL OR SOLE PROPRIETOR:

BY:
                              (Signature)



              IF DISTRIBUTOR IS PARTNERSHIP: (all partners must sign)

BY:
                    (Signature)                                   (Printed Name)

BY:
                    (Signature)                                   (Printed Name)

BY:
                    (Signature)                                   (Printed Name)

                          IF DISTRIBUTOR IS CORPORATION:

BY:
          (Signature & Title of Authorized Officer)               (Printed Name)


Recommended By:                                       Accepted:

                                                      MEDICO™ INSURANCE COMPANY



                                                      By

                                                      Title




MI-DIST                                      6                                     02132008
                                                                                   Medico™ Insurance Company
                                                                1515 South 75th Street, Omaha, Nebraska 68124

Distributor Direct Deposit Authorization

Instructions
Please complete Parts A through C, attach a voided check, and return to the Home Office with your
contracting papers.


Part A: Bank Account Holder Personal Information – Please Print

Name

Address
                Street Address                           City                  State                 Zip

Phone No.                                           E-mail Address

Part B: Bank Account Information

Start Direct Deposit ˆ      Change Account Information ˆ


              Please Attach A Voided Check
Checking ˆ     Savings ˆ

Routing Number


Account Number


Part C: Bank Account Holder(s) Signature(s)

I (We) give permission to Medico™ Insurance Company to automatically make payments to my (our) bank
account of my commissions. This authorization will remain in force unless I (we) cancel it or my (our) bank
account is closed.

Signature                                                                         Date
                  As it appears on bank records.

Signature                                                                         Date
                  If joint account.




MI9F-4320                                                                                             01142008
                                                                                            Medico™ Insurance Company
                                                                                        Medico™ Life Insurance Company
                                                                         1515 South 75th Street y Omaha, Nebraska 68124



                                    BUSINESS ASSOCIATE AGREEMENT

The undersigned on behalf of himself, his partnership or corporation (hereinafter referred to as “Business
Associate”) and Medico™ Insurance Company/Medico™ Life Insurance Company of Omaha, Nebraska,
(hereinafter referred to “Covered Entity”) in consideration of the mutual covenants, agreements, and promises
hereafter contained and for good and valuable consideration, receipt of which is hereby acknowledged, do
hereby agree as follows:

Terms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms in the
Privacy Rule.

Definitions

    a. Business Associate. "Business Associate" shall mean the undersigned individual, partnership, or
       corporation.

    b. Covered Entity. "Covered Entity" shall mean Medico™ Insurance Company/Medico™ Life Insurance
       Company.

    c. Individual. "Individual" shall have the same meaning as the term "individual" in 45 CFR § 164.501 and
       shall include a person who qualifies as a personal representative in accordance with 45 CFR §
       164.502(g).

    d. Privacy Rule. "Privacy Rule" shall mean the Standards for Privacy of Individually Identifiable Health
       Information at 45 CFR Part 160 and Part 164, Subparts A and E.

    e. Protected Health Information. For purposes of this Agreement, “Protected Health Information,” as
       defined at 45 C.F.R. § 160.103, and as may be periodically revised or amended by the U.S. Department
       of Health and Human Services, the U.S. Congress or other federal agency, means information that is
       received from, or created or received on behalf of Covered Entity and is information about an individual
       which relates to the past, present or future physical or mental health or condition of an individual; the
       provision of health care to an individual; or the past, present, or future payment for the provision of
       health care to an individual. Protected Health Information also either identifies the individual or there is
       a reasonable basis to believe the information can be used to identify the individual. Protected Health
       Information pertains to both living and deceased individuals. Protected Health Information includes
       Electronic Protected Health Information as defined at 45 C.F.R. § 160.103 that is received from,
       or created or received on behalf of Covered Entity.

    f. Required By Law. "Required By Law" shall have the same meaning as the term "required by law" in 45
       CFR § 164.501.

    g. Secretary. "Secretary" shall mean the Secretary of the Department of Health and Human Services or his
       designee.




U9F-4133                                                      1                                                 06012006

                        1515 South 75th Street y Omaha, NE 68124 y ph 402-391-6900 y fax 402-391-6489
                             mail address: P.O. Box 3477 y Omaha, NE 68103 y www.gomedico.com
Obligations and Activities of Business Associate

    a. Business Associate agrees to not use or disclose Protected Health Information other than as permitted or
       required by the Agreement or as Required by Law.

    b. Business Associate agrees to use appropriate safeguards to prevent use or disclosure of the Protected
       Health Information other than as provided for by this Agreement.

    c. Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to
       Business Associate of a use or disclosure of Protected Health Information by Business Associate in
       violation of the requirements of this Agreement.

    d. Business Associate agrees to report to Covered Entity any use or disclosure of the Protected Health
       Information not provided for by this Agreement of which it becomes aware.

    e. Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides
       Protected Health Information received from, or created or received by Business Associate on behalf of
       Covered Entity, agrees to the same restrictions and conditions that apply through this Agreement to
       Business Associate with respect to such information.

    f. Business Associate agrees to provide access, at the request of Covered Entity, during the normal
       business hours, to Protected Health Information in a Designated Record Set, to Covered Entity or, as
       directed by Covered Entity, to an Individual in order to meet the requirements under 45 CFR § 164.524.
       If a Business Associate does not have Protected Health Information in a Designated Record Set this
       provision does not apply.

    g. Business Associate agrees to make any amendment(s) to Protected Health Information in a Designated
       Record Set that the Covered Entity directs or agrees to pursuant to 45 CFR § 164.526 at the request of
       Covered Entity or an Individual, during normal business hours. If a Business Associate does not have
       Protected Health Information in a Designated Record Set this provision does not apply.

    h. Business Associate agrees to make internal practices, books, and records, including policies and
       procedures and Protected Health Information, relating to the use and disclosure of Protected Health
       Information received from, or created or received by Business Associate on behalf of, Covered Entity
       available to the Covered Entity, or to the Secretary or someone designated by the Secretary, during
       normal business hours for purposes of the Secretary determining Covered Entity's compliance with the
       Privacy Rule.

    i. Business Associate agrees to document such disclosures of Protected Health Information and
       information related to such disclosures as would be required for Covered Entity to respond to a request
       by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45
       CFR § 164.528.

    j. Business Associate agrees to provide to Covered Entity or an Individual, during normal business hours,
       information collected in accordance with Section i, above, of this Agreement, to permit Covered Entity
       to respond to a request by an Individual for an accounting of disclosures of Protected Health Information
       in accordance with 45 CFR § 164.528.

    k. Business Associate agrees to implement administrative, physical and technical safeguards that will
       reasonably and appropriately protect the confidentiality, integrity, and availability of Electronic
       Protected Health Information.

U9F-4133                                                2                                                  06012006
    l. Business Associate shall report to Covered Entity any security incident relating to Electronic Protected
       Health Information of which it becomes aware. A security incident is defined at 45 C.F.R. § 164.304 as
       “the attempted or successful unauthorized access, use, disclosure, modification, or destruction of
       information or interference with system operations in an information system.”

Permitted Uses and Disclosures by Business Associate

General Use and Disclosure Provision

           Except as otherwise limited in this Agreement, Business Associate may use or disclose Protected Health
           Information to perform functions, activities, or services for, or on behalf of, Covered Entity as specified
           in current or subsequent written agreements detailing the duties and obligations of the parties, provided
           that such use or disclosure would not violate the Privacy Rule if done by Covered Entity or the
           minimum necessary policies and procedures of the Covered Entity.

Specific Use and Disclosure Provisions

    a. Except as otherwise limited in this Agreement, Business Associate may use Protected Health
       Information for the proper management and administration of the Business Associate or to carry out the
       legal responsibilities of the Business Associate.

    b. Except as otherwise limited in this Agreement, Business Associate may disclose Protected Health
       Information for the proper management and administration of the Business Associate, provided that
       disclosures are Required By Law, or Business Associate obtains reasonable assurances from the person
       to whom the information is disclosed that it will remain confidential and used or further disclosed only
       as Required By Law or for the purpose for which it was disclosed to the person, and the person notifies
       the Business Associate of any instances of which it is aware in which the confidentiality of the
       information has been breached.

    c. Except as otherwise limited in this Agreement, Business Associate may use Protected Health
       Information to provide Data Aggregation services to Covered Entity as permitted by 42 CFR §
       164.504(e)(2)(i)(B).

    d. Business Associate may use Protected Health Information to report violations of law to appropriate
       Federal and State authorities, consistent with § 164.502(j)(1).

Obligations of Covered Entity

Provisions for Covered Entity to Inform Business Associate of Privacy Practices and Restrictions

    a. Covered Entity shall notify Business Associate of any limitation(s) in its notice of privacy practices of
       Covered Entity in accordance with 45 CFR § 164.520, to the extent that such limitation may affect
       Business Associate's use or disclosure of Protected Health Information.

    b. Covered Entity shall notify Business Associate of any changes in, or revocation of, permission by
       Individual to use or disclose Protected Health Information, to the extent that such changes may affect
       Business Associate's use or disclosure of Protected Health Information.

    c. Covered Entity shall notify Business Associate of any restriction to the use or disclosure of Protected
       Health Information that Covered Entity has agreed to in accordance with 45 CFR § 164.522, to the
       extent that such restriction may affect Business Associate's use or disclosure of Protected Health
       Information.

U9F-4133                                                    3                                                  06012006
Permissible Requests by Covered Entity

Covered Entity shall not request Business Associate to use or disclose Protected Health Information in any
manner that would not be permissible under the Privacy Rule if done by Covered Entity.

Term and Termination

    a. Term. The Term of this Agreement shall be effective as of the date of execution and shall terminate
       when all of the Protected Health Information provided by Covered Entity to Business Associate, or
       created or received by Business Associate on behalf of Covered Entity, is destroyed or returned to
       Covered Entity, or, if it is infeasible to return or destroy Protected Health Information, protections are
       extended to such information, in accordance with the termination provisions in this Section.

    b. Termination for Cause. Upon Covered Entity's knowledge of a material breach by Business Associate,
       Covered Entity shall either:

           1. Provide an opportunity for Business Associate to cure the breach or end the violation and
              terminate this Agreement and all other Agreements between the parties if Business Associate
              does not cure the breach or end the violation within the time specified by Covered Entity;

           2. Immediately terminate this Agreement and all other Agreements if Business Associate has
              breached a material term of this Agreement and cure is not possible; or

           3. If neither termination nor cure is feasible, Covered Entity shall report the violation to the
              Secretary.

    c. Effect of Termination.

           1. Except as provided in paragraph (2) of this section, upon termination of this Agreement, for any
              reason, Business Associate shall return or destroy all Protected Health Information received from
              Covered Entity, or created or received by Business Associate on behalf of Covered Entity. This
              provision shall apply to Protected Health Information that is in the possession of subcontractors
              or agents of Business Associate. Business Associate shall retain no copies of the Protected
              Health Information.

           2. In the event that Business Associate determines that returning or destroying the Protected Health
              Information is infeasible, Business Associate shall provide to Covered Entity notification of the
              conditions that make return or destruction infeasible. Upon written notice that return or
              destruction of Protected Health Information is infeasible, Business Associate shall extend the
              protections of this Agreement to such Protected Health Information and limit further uses and
              disclosures of such Protected Health Information to those purposes that make the return or
              destruction infeasible, for so long as Business Associate maintains such Protected Health
              Information.

Miscellaneous

    a. Regulatory References. A reference in this Agreement to a section in the Privacy Rule means the section
       as in effect or as amended.

    b. Amendment. The Parties agree to take such action as is necessary to amend this Agreement from time to
       time as is necessary for Covered Entity to comply with the requirements of the Privacy Rule and the
       Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.

U9F-4133                                                 4                                                    06012006
    c. Survival. The respective rights and obligations of Business Associate under Section c "Effect of
       Termination" of this Agreement shall survive the termination of this Agreement.

    d. Interpretation. Any ambiguity in this Agreement shall be resolved to permit Covered Entity to comply
       with the Privacy Rule.

The undersigned on behalf of himself, the partnership, or corporation is executing this Agreement solely in
reliance upon his own knowledge, belief and judgment, and not upon any representations made by the Covered
Entity or others on its behalf.

I have read the foregoing Agreement and understand its terms and freely and voluntarily sign.

Dated at                                                , this           day of                     , 20          .


                        (Signature)


                          (Name)


                          (Title)


       (Individual, Partnership or Corporation Name)




U9F-4133                                               5                                                   06012006
                                                                       Medico™ Insurance Company
                                                                  Medico™ Life Insurance Company
                                                    1515 South 75th Street y Omaha, Nebraska 68124




   PRODUCER LIFE REPLACEMENT POLICIES AND PROCEDURES

PURPOSE OF THESE POLICIES/PROCEDURES:
The purpose of this document is to provide guidance for the suitability of sales of life insurance
and annuities to protect consumers. The goal is to ensure that all sales and replacements are
suitable based on the totality of the particular applicant’s circumstances, including, but not
limited to:
    1. The applicant’s income, age and need for insurance; and
    2. The values, benefits and costs of the applicant’s existing insurance program, if any, when
        compared to the values, benefits and costs of the recommended policy or policies.
Suitable or suitability refer to a sale, replacement or recommendation for a sale or replacement
that meets the needs and goals of the applicant based upon reasonable inquiry concerning the
applicant’s insurance objectives, financial situation, age and other relevant information.
Suitability is determined based on the circumstances that exist at the time of the
recommendation. These standards must be adhered to in marketing and issuing all life insurance
products.

DEFINITION OF REPLACEMENT:
Replacement is a transaction in which a new policy or contract is to be purchased, and it is
known or should be known by the proposing producer and/or Company that by reason of the
transaction, an existing policy or contract has been or will be:
    1. Lapsed, forfeited, surrendered or partially surrendered, assigned to the replacing insurer
        or otherwise terminated;
    2. Converted to reduced paid-up insurance, continued as extended term insurance, or
        otherwise reduced in value by the use of nonforfeiture benefits or other policy values;
    3. Amended so as to effect either a reduction in benefits or in the term for which coverage
        would otherwise remain in force or for which benefits would be paid;
    4. Reissued with any reduction in cash value; or
    5. Used in a financed purchase (which involves the purchase of a new policy involving the
        actual or intended use of funds obtained by the withdrawal or surrender of, or by
        borrowing from values of an existing policy to pay all or part of any premium due on the
        new policy. If the withdrawal, surrender or borrowing involved is used to pay premiums
        on a new policy issued by the same company, it is a replacement within 4 months before
        or 13 months after the effective date of the new policy).

Replacement is not an issue if the new policy is replacing:
   1. Credit life insurance;
   2. Group life insurance and annuities where there is no direct solicitation by a producer;
   3. Group life insurance and annuities used to fund prepaid funeral contracts;
   4. A policy with the same Company when a contractual change or conversion privilege is
      being exercised or when pursuant to a program filed and approved by the state
      Department of Insurance;




U9F-4240                                        1                                         01112007
   5. Life insurance under a binding or conditional receipt issued by the same Company;
   6. A policy used to fund a pension or welfare plan covered by ERISA, or a plan described
       by IRS Code Sections 401(a), 401(k), 403(b), 414 or 457, unless the plan is funded solely
       by contributions an employee elects to make;
   7. A policy paid for entirely by the policyholder’s employer or by an association of which
       the policyholder is a member;
   8. Nonconvertible term life insurance that will expire in 5 years or less and cannot be
       renewed;
   9. Immediate annuities that are purchased with proceeds from an existing contract (not
       policy); or
   10. Structured settlements.

GENERAL SUITABILITY STANDARDS:
Replacing an existing life insurance policy with a new policy is generally not in the applicant's
best interest; however, replacement is not something that should be avoided altogether. There
are circumstances where it may be beneficial to replace an existing policy with a new one.

Examples of situations in which replacement MAY be suitable:
   1. When improved health or mortality across the general population results in the same
       insurance coverage at a lower cost. The adoption of the 2001 CSO mortality table may
       make a new policy more cost-effective.
   2. When conversion to a new single–premium, paid-up policy eliminates the need for future
       payments. The applicant may benefit from a death benefit that is secure rather than
       making periodic payments.
   3. When a new policy may provide increased benefits for the same premium or the same
       benefits at a lower premium.
   4. When the applicant’s insurance needs have changed.
   5. When the applicant has a variable life policy and prefers a whole life policy which has
       guaranteed cash values and where investment decisions are not required.
   6. When the applicant wants to remove a large loan on the existing policy by using that
       policy’s cash value.
   7. When the applicant is concerned with the insurance company or producer that issued or
       marketed the existing policy.
   8. When the applicant’s existing policy has a low guaranteed return.
   9. When the applicant chooses to change the death benefit of an existing policy.
   10. When an existing policy has a low minimal return or high expenses.
   11. When the applicant’s health has improved and the existing insurer will not consider the
       change in health status.
   12. When the existing policy does not charge a nonsmoker a lesser premium.

Examples of situations in which replacement MAY NOT be in an applicant’s best interest:
   1. When a life insurance policy includes early surrender charges, which can reduce the
      amount of cash value available toward the new policy.
   2. When the applicant’s premium may increase, such as for a decline in the applicant’s
      health status.
   3. When there are unfavorable tax consequences caused by surrendering an existing policy,
      such as a potential tax on outstanding policy loans.
   4. When there is no demonstrated benefit to the policyholder.




U9F-4240                                        2
PROCEDURE FOR PRODUCER SOLICITATION:
The producer must disclose all pertinent information about new and existing policies so that the
applicant can make an intelligent choice among available products. Based on the information
provided by the applicant and the producer’s experience, the producer must have reasonable
grounds for believing that the recommended policy is suitable for the applicant.

If the policy is believed to be suitable, the producer may take an application for the life product.
The producer must be sure it is documented on the application whether or not the applicant has
existing life insurance or annuities in force. If the answer is “no,” the producer’s duties with
regard to this procedure are completed. If the answer is “yes,” the producer (TN producers,
please see NOTE below) must comply with the following:

   1. The producer must present and read Replacement Notice MI9F-4231 or M9F-4231 aloud
      to the applicant. The applicant must initial in the appropriate blank on the form if he or
      she does not want the notice read aloud. The producer must assist the applicant in
      completing the notice, including listing all existing life policies and/or annuities to be
      replaced, properly identified by name of insurer, the policyholder and contract number.
      If a contract number has not been assigned by the existing insurer, other identifying
      information such as an application or receipt number must be provided. This form must
      be completed in duplicate: one copy must be left with the applicant, and the other must
      be submitted to the Company with the application.

   2. The producer must leave the original or a copy of all written or printed communications
      used for presentation to the applicant.* The producer must complete the certification on
      the bottom of Replacement Notice MI9F-4231 or M9F-4231 to verify compliance with
      this requirement. Any electronically presented sales material must be provided in printed
      form to the applicant no later than at the time of policy delivery. *Producers may not
      utilize any communications that have not been reviewed and approved in advance
      by the Company.

NOTE: In Tennessee, any producer who has been licensed for less than 120 days by the
Tennessee Department of Commerce and Insurance must send the Company notice by certified
or registered mail, at least 10 days prior to taking an application for a replacement policy, stating
that the producer intends to replace existing insurance, and include the name of the existing
insurer and the policy number of the policy to be replaced.

COMPANY REVIEW OF REPLACEMENTS:
Ultimately it is the responsibility of the Company to use and enforce the suitability standards it
has developed in determining whether issuing a policy or contract to the applicant is suitable. All
life replacements will be reviewed by the Underwriting Director of the Company. If the
Underwriting Director determines that the applicant does not meet the suitability standards, or if
the applicant has declined to provide the information requested, the Underwriting Director may
reject the application by sending Letter 400 to the applicant. The Company will not offer or
recommend replacement except when it can be clearly demonstrated that the replacement is in
the best interest of the applicant and meets his or her needs, wants or desires.

A signed replacement form is required with every replacement application and with every
application when the applicant has life insurance in force, even if replacement is not
contemplated. If documents are not completed in their entirety they will be returned to the
producer (if the application resulted from producer solicitation) for follow-up. Failure to respond
to a request for additional information in a timely manner will result in declination of the
application as unsuitable.

U9F-4240                                          3
NOTE: The Company cannot accept any replacement applications from a Tennessee producer
who has been licensed for less than 120 days by the Tennessee Department of Commerce and
Insurance unless the producer has sent the Company notice by certified or registered mail, at
least 10 days prior to taking an application for a replacement policy, stating that the producer
intends to replace existing insurance, and include the name of the existing insurer and the policy
number of the policy to be replaced. Once the notice has been received by the Company, the
Company must immediately forward it to the existing insurer by certified or registered mail.

COMPANY REQUIREMENTS IF A COMPANY POLICY IS BEING REPLACED:
• Conservation
  At the current time, the Company will not attempt to conserve any business. If the
  Company decides to start conserving, this procedure will be clarified.

   Producers must contact the Company Policyholder Service Department as soon as possible
   when they are notified by a policyholder of a policy cancellation or surrender for cash value.
   If it is decided to attempt to conserve the business, the Company must provide the policy-
   holder with a policy summary for the existing life insurance within 20 days from receipt of
   the notice of replacement. All materials used must be left with the policyholder.

COMPANY NOTIFICATION OF PRODUCERS REGARDING REPLACEMENT
REQUIREMENTS:
The Company is responsible for notifying producers of the Policies and Procedures relevant to
producer solicitation of life insurance, and the Company’s position regarding the appropriateness
of replacements. Each producer will be provided with a copy of the Producer Life Replacement
Policies and Procedures (Form U9F-4240). Each producer must sign an acknowledgement
(Form U9F-4241) stating the he or she has received, read and will adhere to guidelines as stated.
A producer is not eligible to solicit life insurance for the Company if this acknowledgement
is not returned to the Company. No applications submitted by the producer will be processed
unless the Company is in receipt of this acknowledgement. A copy of the acknowledgement will
be saved in the producer’s file. Until the signed acknowledgement is received, a flag will not be
set on the PAPR screen (the flag must be set in order for a policy sold by a particular producer to
be issued). When received, the signed acknowledgement will be saved in the producer’s file.

COMPLIANCE WITH THESE POLICIES AND PROCEDURES:
Violation of these policies and procedures will subject the producer to sanctions up to and
including termination of appointment.

DISCLAIMER:
These Policies and Procedures were written based upon the NAIC Life Insurance And Annuities
Replacement Model Regulation and state requirements. If the Company decides to sell life
insurance in additional states, these Policies and Procedures will be reviewed for compliance in
those states.




U9F-4240                                         4
                                                                     Medico™ Insurance Company
                                                                 Medico™ Life Insurance Company
                                                  1515 South 75th Street y Omaha, Nebraska 68124




             ACKNOWLEDGEMENT OF RECEIPT
   PRODUCER LIFE REPLACEMENT POLICIES AND PROCEDURES

I acknowledge that I have received, read and will adhere to the guidelines stated in the Producer
Life Replacement Policies and Procedures for Medico™ Insurance Company and Medico™ Life
Insurance Company, Form U9F-4240. I understand that violating any of the stated policies or
procedures will subject me to sanctions up to and including termination of appointment.

I am aware that      I will not be eligible to solicit life insurance for the Company if this
acknowledgement       is not returned to the Company. When completed, please return this
acknowledgement      to: Marlene Albertsen, Manager of Agent Services, Medico™ Group, 1515
South 75th Street,   Omaha, NE 68124. You may also fax the form to: Marlene Albertsen at
(402) 398-0887.



Print Name                                      Producer Number


Agency Name (if applicable)                     Date


Original Signature




U9F-4241                                                                               06012006

								
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